By Vince Bielski
The opioid crisis that helped kill a record 108,000 Americans last year — and more than one million since 1999 — is by now a well-known tragedy. Less understood is that many if not most of these deaths, now largely from fentanyl, are preventable.
Medications like buprenorphine are proven lifesavers, cutting fatalities in people with opioid use disorder roughly in half. But the problem is that only a small fraction of the people in the U.S. addicted to opioids — a number variously estimated at between 3 million and 7.6 million — have access to these medications.
Even fewer are getting the optimal combination of medication plus counseling and group therapy — even though most people struggling with addiction also suffer from a mental health disorder.
A host of factors contribute to this widening treatment gap — a drastic shortage of the most effective programs and addiction providers, inadequate reimbursement levels in the federal Medicaid program and bureaucratic regulations that have limited the ability of physicians to prescribe treatments like buprenorphine. It’s part of the gold-standard approach known as medication-assisted treatment, or MAT.
The Biden administration wants to reverse these trends. It has incrementally boosted funding for treatment, including MAT. But barriers abound.
Adrianna LeBlanc, 37, is one of many substance abusers who have been denied MAT to overcome their opioid addiction. When she was 20, the young mother in North Carolina started using cocaine and opioids while in an abusive relationship with her addicted boyfriend. Before long, she lost custody of her kids and became homeless.
After about six years, when she could no longer endure the misery, LeBlanc sought out treatment. She had heard that Suboxone, the brand name for a medication that combines buprenorphine and naloxone, was a miracle drug that helps people get clean. So she asked a doctor at a treatment center in Alamance County, North Carolina, to prescribe it.
“The doctor said she felt I was there to get Suboxone because it was a legal way to get high,” LeBlanc says. “And I was like, ‘What? Are you kidding me?’ I was in tears when I left. She made me feel like there was no help for me. So I went back on the streets for the next three years.”
LeBlanc’s road to recovery was unusual — she got clean while in prison for car theft and stayed clean for several years until she started using prescription pain medications after suffering spinal complications from childbirth. Once again, she sought out Suboxone, and this time, a doctor at Freedom House Recovery Center in Chapel Hill wrote a script for her in 2019.
Since then, LeBlanc has taken 24mg of Suboxone daily, and except for a brief relapse with cocaine, it has helped turn her life around. She works full time at a meat smokehouse, regained custody of her three older children and feels safe from the temptations of illegal drug use. “It doesn’t make me high or sleepy or affect how I feel,” she says. “But if anything comes my way during the day, I know that I’m safe. Suboxone has been everything to me.”
LeBlanc’s years-long struggle to get Suboxone illustrates a glaring inequity: While 70% of adult diabetics in the U.S. routinely use oral medications that keep them alive, only about 11% of opioid users receive MAT, according to a 2020 report by the Substance Abuse and Mental Health Services Administration (SAMHSA).
“The treatment system is not working. Only one in ten people with substance use disorder are getting evidence-based care including MAT,” says Shawn Ryan, the chief medical officer of BrightView, one of the largest providers of addiction treatment in the Midwest. “We had the highest number of overdose deaths on record in 2021 and it probably will get worse.”
The complicated story of why so few users of heroin, fentanyl and prescription opioids undergo treatment begins with the lingering stigma in much of the U.S. that equates drug addiction with moral depravity or personal weakness. The stigma makes it easy for communities to oppose treatment centers and hard for politicians to fund them.
Treatment specialists are trying to change this moralistic narrative with medical facts. The success of MAT suggests that addiction operates much like a chronic medical condition — manageable with medications but hard to cure.
Buprenorphine and methadone are like a bridge over a scary gorge to recovery. The long-acting opioids reduce the physically intense withdrawal effects from highly potent opioids like fentanyl that frighten users and stop some of them from trying to clean up.
But opioid disorder is different from illnesses like diabetes in one important way: Addicts sometimes resist treatment since getting high is a lot easier than enduring the pain of opioid detox.
San Francisco, one of the nation’s overdose hotspots, experienced the difficulties of getting users into treatment at its Tenderloin Linkage Center earlier this year. The idea was to coax people off the street and into treatment. But the center morphed into a de facto safe consumption site — in apparent violation of state law — and attracted widespread controversy. Facing criticism, Mayor London Breed shut it down.
For those who are ready to get clean, there’s a problem: Today’s underfunded MAT system isn’t big enough to accommodate them. Medicaid, the federal health insurance program available to disabled people and, in some states, to those with low incomes, reimburses addiction treatment programs at only 50% to 70% of what private insurers pay, says Ryan of BrightView. A study released in July found that Medicaid rates for substance use treatment were about a third lower than rates paid by Medicare. Other services, like nursing and counseling, are also underfunded, keeping many specialists from wanting to work in the field.
Compounding the problem are some of the most burdensome regulations in all of medicine. To provide even a limited amount of buprenorphine, physicians must have special so-called X-waivers from the Drug Enforcement Administration. And many states have their own set of treatment rules dictating when doctors can see patients, dosage limits and when they can come off meds. This is not done in the rest of American medicine, says Ryan.
If primary care physicians could more easily prescribe MAT from their general practices, it might greatly expand the number of patients served. It would also remove some of the stigma associated with going to an addiction treatment center, often located in marginalized communities.
Patients are 50% more likely to start treatment and stick with it in a primary care setting rather than an addiction treatment center, according to a 2017 study by the Commonwealth Fund. In California, the Center for Care Innovations has helped more than 70 primary care health centers create or expand MAT programs, increasing the number of doctors prescribing MAT by 150 and the number of patients receiving it by 2,000.
“With Covid, the country has clearly shown that we can respond to a crisis with a massive national effort,” Ryan says. “But with the opioid crisis, we have no financial incentives in place and super complicated regulations, so many physicians don’t want to do treatment. If we remove these barriers, the system will build itself.”
Building more treatment capacity also depends on increasing the workforce of trained addiction specialists who can prescribe MAT, and who also could supervise or consult with prescribing primary care physicians — just as psychiatrists often consult with pediatricians or family doctors who prescribe medicines for attention deficit disorder or depression.
In 2020, an estimated 3,200 certified addiction medicine specialists worked in a field that needs about 44,000, according to a SAMHSA workforce report. The workforce also needs three times more nurses and five times more psychologists. Ryan’s BrightView, with treatment locations in six states, has 53 pages of job openings on its website.
The American Board of Medical Specialties waited until 2015, years after overdose deaths began surging, to address the shortage of trained specialists by recognizing addiction medicine as a subspecialty. Only about half of U.S. medical schools now have addiction medicine fellowships.
With some 16,000 alcohol and drug treatment centers spread across the U.S., and only half of those offering MAT, opioid users who seek help often end up on waiting lists. Americans who can pay $20,000 for opioid treatment at private residential centers typically get admitted within a day. But everyone else and those on Medicaid have to wait an average of 14 days at most nonprofit programs, according to an audit of residential opioid centers by the Harvard T.H. Chan School of Public Health.
“These patients are in peril,” says Michael Barnett, an assistant professor of health policy and management at Harvard who worked on the 2021 study. “Some will overdose and die or commit suicide during that waiting period. I can think of no other immediately life-threatening medical condition where patients are made to wait for two weeks.”
The Harvard audit, conducted as a “secret shopper” study of more than 600 mostly non-MAT facilities, revealed a lack of professional standards and raised concerns about the quality of care. More than 40% of the profit-seeking centers offered admission over the phone without doing a clinical evaluation to see if their services matched clients’ needs. Most also offered recruitment perks like gourmet food and free transportation and on average charged twice as much — about $750 a day — as nonprofit programs.
“I hate to say this, because I work in this field, but we have some lousy treatment programs,” says Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford and an adviser to federal health officials on substance abuse treatment. “That’s another challenge. We have weaker quality standards than in other areas of medicine.”
Clinical psychologist Emily Guarnotta says inadequate licensing requirements and staff training are behind the poor performance at some facilities. She interned during graduate school for a year at Sovereign Health, a network of treatment centers based in Southern California, before it was raided by FBI agents looking for evidence of fraud a few years ago and closed several facilities. She says Sovereign hired unlicensed clinicians while advertising that clients would be treated by licensed professionals.
“I’ve met many drug and alcohol counselors who were really effective and wonderful,” says Guarnotta, who is now in private practice in New York. “Some of them were in recovery themselves and I observed counselors coming to work under the influence and having inappropriate relationships with clients. The licensing requirements aren’t stringent enough and this creates problems.”
In the early days of drug treatment in the 1960s, the field was dominated by therapeutic communities that preached abstinence from all drugs, including medications like methadone. These self-help programs were based on the idea that a lack of discipline rather than brain chemistry caused addiction. The path to recovery required personal transformation unassisted by medications.
The harshest of these communities took steps like making adults wear diapers and placing them in a chair in the middle of a room surrounded by other clients, says Linda Sacco, the chief clinical officer at Phoenix House, a residential treatment center with locations across the country. This was considered therapy.
“The idea was to totally break them down before you build them back up,” says Sacco. “But over the years many therapeutic communities learned that this type of treatment was actually damaging to clients, particularly those with mental health issues.”
Encouraged by research findings and federal funding, Phoenix House is one of many former therapeutic communities that evolved into integrated and evidence-based treatment centers. They kept what worked, such as counseling, while incorporating medications into their programs. But to this day, some therapeutic communities still refuse to work with clients who use the FDA-approved meds like buprenorphine, arguing erroneously that they are another form of addiction.
The therapeutic community approach, used at DeLancey Street in San Francisco, can be effective with certain people like those who’d spent time in prison, says David Smith, the doctor who founded the Haight Ashbury Free Clinic and was a transformative figure in the treatment field. But the severe withdrawal symptoms from fentanyl, which is up to 50 times more potent than heroin, make MAT much more effective in keeping clients in treatment and preventing relapses, Smith says.
“The old-school approach works for some people, so we need a diversity of options,” Smith says. “But MAT is the mainstay of treatment for opioid use disorder.”
Constantine Diakolios had a successful practice in internal medicine before switching fields two decades ago — a move that was cemented by a chance encounter with a former client at a diner. A waitress and former addict approached Diakolios and thanked him for saving her life at a Salvation Army treatment program in New York.
“She said, ‘I got this job, I got an apartment and I got my daughter back.’ And she hugged me,” says Diakolios, now the medical director of Sunrise House Treatment Center in New Jersey. “That’s what made me realize that I had found my calling.”
After detoxing more than 30,000 patients, Diakolios understands the clinical challenges that make treating opioid addiction so difficult. Doctors struggle to gain the trust of patients, who fear the sweats, muscle pain, diarrhea and nausea that come during detox. Coming off fentanyl is the worst, he says, because the fast-acting opioid, which produces euphoric effects for about 30 minutes, accelerates and intensifies withdrawal symptoms.
Calibrating the timing and determining the optimal amount of buprenorphine to give patients is tricky, he says, based on when they last used opioids and how much they took. If a doctor makes a mistake, the patient’s withdrawal will be even tougher.
“Detoxing a patient is very difficult because patients are extremely sick,” Diakolios says. “A lot of doctors and nurses don’t have the knowledge to do it.”
After detox, which lasts about six days, less severe symptoms arrive in waves and eventually disappear. Some patients can stop taking medications. Many others use them for decades in small doses that don’t produce euphoria but do control cravings for opioids.
The keys to post-detox recovery are therapy and support from family and groups like Narcotics Anonymous to help patients piece their lives back together, Diakolios says. Without such help, he adds, up to 95% of patients relapse.
This is particularly true with patients who also suffer from a mental health disorder — about 57% of substance users in treatment, according to the 2020 SAMHSA report. People with untreated depression or anxiety are much more likely to have a substance abuse problem than the general population. They might turn to alcohol and other substances to push away the blues and eventually become addicted. But drug use will likely worsen the psychiatric condition, making the patients even harder to treat.
For MAT centers like Phoenix and Sunrise, the mental health programs — including one-on-one, group therapy, and 12-step counseling — are just as important as the buprenorphine. “We have to treat both the addiction and the psychiatric disease,” says Diakolios. “They are two fires in the same house. We need to put them both out for the house to stop burning.”
The upside is that once a patient with a dual diagnosis stops using drugs, the depressive symptoms tend to lift. “If you can get them over the hard part and into recovery, then the jittery and sad person starts to smile more and they seem emotionally lighter and happier,” says Humphreys of Stanford. “It’s a common experience.”
That said, a full recovery from opioids is hard to achieve. Only about a third of patients who access MAT stop abusing drugs and become dramatically better, Humphreys says. Those with family support and a job to go back to have a better chance of making it.
Another third benefit from treatment and start their next chapter, able to hold down a job and seemingly live a normal life. But they struggle to stay clean and often slide back into drug use and perhaps treatment.
“They are like patients who get coronary artery bypass grafts,” Humphreys says. “These chronic diseases have to be managed over long periods of time.”
The final third? Six to 12 months after treatment they are essentially the same, craving dope and possibly living on the streets. In San Francisco, some 4,000 homeless people also suffer from mental illness and addiction, according to a 2019 city estimate. The next year, a record 711 drug users died in the city from an overdose, mostly from fentanyl.
Since then, the number of fatalities in San Francisco has been creeping down, thanks partly to the availability of Narcan, a medication that restores breathing after an opioid overdose. It’s a sign, however small, that the opioid crisis perhaps can be contained as MAT expands under the Biden administration.
The pandemic opened the federal spending spigot in 2021, giving the administration its best shot to fund opioid treatment. It provided more than $3 billion in additional funding to SAMHSA for block grants to states for drug treatment and prevention.
But despite the White House’s request for another big infusion in the 2022 budget, the Democratic Congress only approved a token increase of about $100 million for the agency’s substance abuse treatment pipeline of about $3.9 billion. That’s far short of the hundreds of billions needed over time to build out MAT services and get a handle on the epidemic, says BrightView’s Ryan.
In the meantime, he has a legislative battle to win. The House recently passed measures to end the requirement that doctors get a DEA waiver to administer buprenorphine and to add a requirement that physicians get eight hours of training before administering medications to drug abusers. The American Society of Addiction Medicine is pushing for the Senate to pass the measures this year.
“Our strategy is to systematically remove the barriers to treatment, and the DEA waiver is one of many,” says Ryan, the society’s legislative advocacy chair. “I’m cautiously optimistic they will pass.”
If the proposals become law, more doctors will enter the field, treating more patients in primary care settings and at facilities like Phoenix House. Sacco says that means more lives will be saved.
Sacco tells the story of a New York City man in his late 20s whose recovery is typical of many patients who receive MAT. Without a stable home or job, he started using fentanyl, believing it was safe since doctors prescribed it to patients as a painkiller. He survived one overdose, and then a second one last year nearly killed him.
The young man was revived with Narcan. He went through detox in a hospital and then entered a Phoenix House facility in Long Island City. After receiving medications plus one-on-one counseling and group therapy for several months, he left Phoenix House in much better health and spirits than when he arrived.
That didn’t surprise Sacco, who has overseen plenty of recoveries from opioids. “For sure we have saved lives,” she says. “People have said, ‘I would be dead if I hadn’t made the decision to come here for treatment.’”